Pseudomembranous colitis and Parabacteroides distasonis bacteraemia: a rare clinical presentation.

We present the case of a male with end-stage diabetic nephropathy on haemodialysis who initially presented with acute-on-chronic digital ulceration. While awaiting vascular intervention, he became septic with abdominal pain and diarrhoea. Flexible sigmoidoscopy confirmed pseudomembranous colitis secondary to Clostridium difficile. Blood cultures grew Parabacteroides distasonis, a Gram-negative gut anaerobe. Enterobacter cloacae, another Gram-negative anaerobic gut bacilli, was grown in colonic cultures and swabs of the digital ulcers. We hypothesise that the pseudomembranous colitis increased gut translocation and thus led to the systemic spread of both gut anaerobes. This is the first reported case of Parabacteroides distasonis bacteraemia in the context of Clostridium difficile infection. Our patient recovered with antibiotics and went on to have vascular intervention for his digital ulceration.

Choledochoduodenal fistula: a rare complication of acute peptic ulcer bleeding.

A 75-year-old man presented with a 3-week history of melaena and right upper quadrant pain. This was on a background of significant alcohol intake and a complex medical history. He was haemodynamically unstable with investigations indicating a new iron-deficiency anaemia. After resuscitation, urgent intervention was required under general anaesthesia. This involved a triple phase abdominal CT, followed by emergency oesophagogastroduodenoscopy. This revealed deep ulceration with extension to the pancreatic head and common bile duct. There was also evidence of pneumobilia on CT, secondary to a choledochoduodenal fistula. Treatment encompassed an invasive and medical approach. Following treatment, the patient was stable, with follow-up endoscopy exhibiting good duodenal mucosal healing.

Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system.

BACKGROUND AND AIM: Our aim was to evaluate the efficacy and safety of a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EDS-LAMS) for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) in regular clinical practice. METHODS: A retrospective and subsequent prospective analysis was undertaken of all patients who underwent EUS-guided drainage of their PFCs using the EDS-LAMS at 17 tertiary therapeutic endoscopy centers. RESULTS: Two hundred eight cases of EDS-LAMS deployment were attempted in 202 patients (mean age 52.9 years) at time of evaluation. Ninety-seven patients had pancreatic pseudocysts (PPs), 75 walled-off pancreatic necrosis (WOPN), 10 acute peripancreatic fluid collections (APFCs), 6 acute necrotic collections (ANCs), and 14 postoperative collections (POCs). Procedural technical success was achieved in 202/208 cases (97.1%). Maldeployment occurred in 7/208 cases (3.4%). Clinical success was achieved in 142/160 (88.8%) patients (PP 90%, WOPN 85.2%, APFC 100%, ANC 75%, POC 100%). Delayed adverse events included stent migration in 15/202 (7.4%), stent occlusion and infection in 16/202 (7.9%), major bleeding in 4/202 (2%), and buried EDS-LAMS in 2/202 (1%). PFC recurrence occurred in 13/142 (9.2%) patients; 9/202 (4.5%) required surgical or radiological intervention for PFC management after EDS-LAMS insertion. CONCLUSIONS: This large international multicenter study evaluating the EDS-LAMS for drainage of PFCs in routine clinical practice suggests that the EDS-LAMS are safe and effective for drainage of all types of PFCs; however, further endoscopic therapy is often required for WOPN. Major bleeding was a rare complication in our cohort.

Pyogenic liver abscess: incidence, causality, management and clinical outcomes in a New Zealand cohort.

AIMS: The determinants, management and outcomes of pyogenic liver abscess [PLA] are changing. We aimed to compare these in a New Zealand cohort. METHODS: We have retrospectively reviewed all PLA cases presenting to Christchurch Hospital over 12 months between 2014 and 2015. RESULTS: Twenty-five cases presented over this period. The incidence was 5/100,000. Eighty percent were Caucasian with overall 4:1 male preponderance. Commonest comorbidities were diabetes, hypertension, atrial fibrillation and immunosuppression. Underlying pancreatico-biliary disease featured in 20%, preceding Whipple's or hepatic resection in 24% and inflammatory bowel disease [IBD] in 12%. Commonest complication was septic shock with intensive care unit admission in four cases. The evident cause was recent Whipple's procedure or hepatic resection (24%), pancreatico-biliary (16%), diverticulitis (12%) and active IBD (8%). Cause remained cryptogenic in 28%. The commonest microorganism was Streptococcus intermedius. The management comprised of: antibiotics alone (n=6), needle aspiration (n=2), catheter drainage (n=14), biliary drainage (n=3), surgical drainage (n=2). These interventions were in accordance with current international recommendations. There were no deaths and the mean length of stay was 10.3 days. CONCLUSION: PLA continues to carry significant morbidity. Demographics, including ethnicity, play an important role. Our tertiary centre cohort may account for higher incidence and better clinical outcomes.

Transition clinics: an observational study of themes important to young people with inflammatory bowel disease.

BACKGROUND: Transition from paediatric to adult services can be stressful and potentially disruptive for adolescents diagnosed with inflammatory bowel disease (IBD). This study aimed to ascertain transition-related factors relevant to young people in New Zealand. METHODS: Adolescents diagnosed with IBD prior to their 16th birthday were asked to participate in focus groups to generate transition-related themes. These themes were used to develop a questionnaire, which was then administered to a second group of young patients. RESULTS: Initial focus groups discussions generated several key themes: these included concerns about meeting new people in unfamiliar surroundings, the importance of shared clinics and assessments for transition readiness. The subsequent transition questionnaire was completed by 53 young people (28 female and 48 with Crohn's disease). The most commonly reported difficulty by those entering transition was meeting a new doctor. This and building a new relationship/trust were the main concerns of respondents who were preparing for or within a transition process. Parental assessment of illness and readiness to transition were not thought to be as important as other factors for determining readiness for transition. The character of their new adult gastroenterologist was the factor felt most likely to make transition easy. CONCLUSIONS: The main concerns of these young patients with IBD, at various stages of transition, were about meeting a new team and building new relationships. Planning and conducting a structured transition process should consider these factors to optimise the process.

Infliximab and adalimumab concentrations and anti-drug antibodies in inflammatory bowel disease control using New Zealand assays.

BACKGROUND: Therapeutic drug monitoring of anti-tumour necrosis factor (TNF) drugs and anti-drug antibodies (ADA) is now recommended in the treatment of inflammatory bowel disease. However, assay types and drug concentration thresholds are still debated. AIM: To correlate inflammatory bowel disease activity in a New Zealand cohort with trough concentrations of infliximab and adalimumab, and ADA using locally developed competitive-binding enzyme-linked immunosorbent assays (ELISA) to establish threshold concentrations. METHODS: Patients with ulcerative colitis (UC) and Crohn disease (CD) from Christchurch and Dunedin on anti-TNF drugs >12 weeks were enrolled. Trough blood samples were assayed for drug and ADA concentrations. Other data included quality of life, blood count, C-reactive protein, albumin, renal function and disease activity indices. RESULTS: Of 103 patients, 53 were on infliximab (36 CD, 15 UC and 2 unclassified) and 50 adalimumab (48 CD and 2 UC). Median (range) infliximab and adalimumab concentrations were 10.5 (0-41) and 9.61 mg/L (0-30). CD remission, Crohn Disease Activity Index <150, correlated with infliximab and adalimumab concentration in CD (infliximab, P = 0.03; adalimumab, P = 0.04), with too few UC patients for analysis. Receiver operator curve analysis suggested a threshold value of 5.1 mg/L for distinguishing active disease from remission for infliximab and 7.3 mg/L for adalimumab in CD. Of 13 patients with infliximab <2 mg/L, 10 were ADA positive by homogeneous mobility shift assay (HMSA), including five with neutralising antibodies using ELISA. Of six with adalimumab <2 mg/L, three were ADA positive using HMSA, including one with neutralising antibodies. CONCLUSION: Using the New Zealand ELISA assay, threshold concentrations of 5 mg/L for infliximab and 7 mg/L for adalimumab are suggested to aid dosing decisions, consistent with results internationally. Both neutralising (ELISA) and non-neutralising ADA (HMSA) are associated with low drug concentrations.